Simple pooling versus combining in meta-analysis

A methodological framework for rigorous systematic reviews: Tailoring comprehensive analyses to clinicians and healthcare professionals

Systematic reviews represent a fundamental study design, providing the highest level of evidence across diverse research inquiries, encompassing both public health and clinical research and practice. However, for healthcare professionals, the process of selecting, synthesizing, and interpreting evidence can be challenging, and requires specialized skills. Therefore, it is imperative to explore innovative solutions aimed at simplifying and making the traditional systematic review process more accessible while ensuring the validity and reliability of results. In this perspective, our research objective is to develop a systematic review framework that, while maintaining a rigorous methodological approach, streamlines the process for healthcare professionals. This study describes such approach in every phase, from the collection of evidence to the writing of the text, creating a guide for the healthcare professional who approaches this type of research. The qualitative and organizational analysis tools are also described, providing useful information for the use of non-paid programs. This systematic review aims to develop a framework with a rigorous methodological approach that allows simplify the process for clinicians and healthcare professionals. The implementation of this methodology in clinical practice offers new perspectives to ensure a thoughtful consideration and application of scientific evidence and opens the way to innovative and easily accessible solutions to facilitate the conduct of systematic reviews in the clinical care setting.

Maintaining ethics, Integrity, and accountability: Best practices for reporting a meta-analysis

This letter addresses the significance of conducting and reporting systematic reviews and meta-analyses using the appropriate methods. It also highlights the importance of implementing the latest guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-2020, which ensures the maintenance of ethics, integrity, and accountability while reporting systematic reviews and meta-analyses.

Systemic antibiotic treatment for meibomian gland dysfunction-A systematic review and meta-analysis

PURPOSE

To review the efficacy and safety of oral doxycycline antibiotics versus macrolides in the treatment of meibomian gland dysfunction (MGD).

DESIGN

Systematic review and meta-analysis.

METHODS

We performed a systematic search of electronic databases for all peer-reviewed published studies which included clinical outcomes of oral antibiotic MGD treatment. Individual study data were extracted and evaluated in a weighted pooled analysis, including total sign and symptom scores, meibomian gland secretion score, tear break-up time (TBUT), fluorescein staining score and rate of complications.

RESULTS

Two thousand nine hundred and thirty-three studies were found, of which 54 were eligible for the systematic review, and six prospective studies were ultimately included for analysis, reporting on 563 cases from three countries. Age of affected patients ranged between 12 and 90 years. Overall, both treatment methods induced improvement in MGD signs and symptoms. In pooled analysis, macrolides were significantly superior in the total signs score (pooled standardized mean difference (SMD) -0.51, 95% confidence interval (CI): -0.99 to -0.03), meibomian gland secretion score (pooled SMD -0.25, 95%CI: [-0.48, -0.03]), TBUT (SMD -0.31, 95%CI: [-0.50, -0.13]) and fluorescein staining score (SMD -1.01, 95%CI: [-1.72, -0.29]). Moreover, while no severe complications were reported for both treatments, the macrolide group exhibited significantly less adverse events (pooled odds ratio 0.24 with a 95% CI of 0.16 to 0.34).

CONCLUSIONS

Both macrolides and tetracyclines are effective treatments for MGD. In this study, macrolides exhibited better efficacy and safety profile compared to tetracyclines.

Transparent reporting of adaptive clinical trials using concurrently randomised cohorts

Adaptive clinical trials have designs that evolve over time because of changes to treatments or changes to the chance that participants will receive these treatments. These changes might introduce confounding that biases crude comparisons of the treatment arms and makes the results from standard reporting methods difficult to interpret for adaptive trials. To deal with this shortcoming, a reporting framework for adaptive trials was developed based on concurrently randomised cohort reporting. A concurrently randomised cohort is a subgroup of participants who all had the same treatments available and the same chance of receiving these treatments. The reporting of pre-randomisation characteristics and post-randomisation outcomes for each concurrently randomised cohort in the study is recommended. This approach provides a transparent and unbiased display of the degree of baseline balance and the randomised treatment comparisons for adaptive trials. The key concepts, terminology, and recommendations underlying concurrently randomised cohort reporting are presented, and its routine use in adaptive trial reporting is advocated.

Cardiovascular disease burden is associated with worsened depression symptoms in the U.S. general population

BACKGROUND

Cardiovascular disease (CVD) and depression are the leading causes of disability in the U.S. Using five cycles (2009-2018) of the U.S. National Health and Nutrition Examination Survey, we examined the cross-sectional association between CVD risk factor burden and depression severity in nonpregnant adults with no history of CVD events.

METHODS

With at least 3000 participants per cycle, the overall N was 18,175. CVD risk factors were ascertained through self-report, lab tests, or medications. The sum of hypertension, diabetes, dyslipidemia, and current smoking represented a CVD risk score variable (range: 0-4). Depression severity was assessed using scores on the 9-item patient health questionnaire: 0-9 (none-mild) and 10-27 (moderate-to-severe). Logistic regression models were performed to investigate the association between CVD risk score categories and moderate-to-severe depression. Cycle-specific odds ratios (OR) were meta-analyzed to obtain a pooled OR (95 % CI) (Q-statistic p > 0.05).

RESULTS

Compared to participants with no CVD risk factors, participants with risk scores of 1, 2, 3, and 4, had 1.28 (0.92-1.77), 2.18 (1.62-2.94), 2.53 (1.86-3.49), 2.97 (1.67-5.31) times higher odds of moderate-to-severe depression, respectively, after adjusting for socio-demographics and antidepressant use (linear trend p < 0.0001). This relationship persisted after additionally adjusting for lifestyle variables.

LIMITATIONS

NHANES data is cross-sectional and self-reported, thus preventing causal assessments and leading to potential recall bias.

CONCLUSIONS

Among U.S. adults, CVD risk factor burden was associated with worsened depression symptoms. Integrated mental and physical healthcare services could improve risk stratification among persons with CVD and depression, possibly reducing long-term disability and healthcare costs.

Metabolic Signatures of Youth Exposure to Mixtures of Per- and Polyfluoroalkyl Substances: A Multi-Cohort Study

BACKGROUND

Exposure to per- and polyfluoroalkyl substances (PFAS) is ubiquitous and has been associated with an increased risk of several cardiometabolic diseases. However, the metabolic pathways linking PFAS exposure and human disease are unclear.

OBJECTIVE

We examined associations of PFAS mixtures with alterations in metabolic pathways in independent cohorts of adolescents and young adults.

METHODS

Three hundred twelve overweight/obese adolescents from the Study of Latino Adolescents at Risk (SOLAR) and 137 young adults from the Southern California Children's Health Study (CHS) were included in the analysis. Plasma PFAS and the metabolome were determined using liquid-chromatography/high-resolution mass spectrometry. A metabolome-wide association study was performed on log-transformed metabolites using Bayesian regression with a g-prior specification and g-computation for modeling exposure mixtures to estimate the impact of exposure to a mixture of six ubiquitous PFAS (PFOS, PFHxS, PFHpS, PFOA, PFNA, and PFDA). Pathway enrichment analysis was performed using Mummichog and Gene Set Enrichment Analysis. Significance across cohorts was determined using weighted Z -tests.

RESULTS

In the SOLAR and CHS cohorts, PFAS exposure was associated with alterations in tyrosine metabolism (meta-analysis p = 0.00002 ) and de novo fatty acid biosynthesis (p = 0.03 ), among others. For example, when increasing all PFAS in the mixture from low (∼ 30 th percentile) to high (∼ 70 th percentile), thyroxine (T4), a thyroid hormone related to tyrosine metabolism, increased by 0.72 standard deviations (SDs; equivalent to a standardized mean difference) in the SOLAR cohort (95% Bayesian credible interval (BCI): 0.00, 1.20) and 1.60 SD in the CHS cohort (95% BCI: 0.39, 2.80). Similarly, when going from low to high PFAS exposure, arachidonic acid increased by 0.81 SD in the SOLAR cohort (95% BCI: 0.37, 1.30) and 0.67 SD in the CHS cohort (95% BCI: 0.00, 1.50). In general, no individual PFAS appeared to drive the observed associations.

DISCUSSION

Exposure to PFAS is associated with alterations in amino acid metabolism and lipid metabolism in adolescents and young adults. https://doi.org/10.1289/EHP11372.

Global prevalence of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in the overweight and obese population: a systematic review and meta-analysis

BACKGROUND

The global burden of non-alcoholic fatty liver disease (NAFLD) parallels the increase in obesity rates across the world. Although overweight and obesity status are thought to be an effective indicator for NAFLD screening, the exact prevalence of NAFLD in this population remains unknown. We aimed to report the prevalence of NAFLD, non-alcoholic fatty liver (NAFL), and non-alcoholic steatohepatitis (NASH) in the overweight and obese population.

METHODS

In this systematic review and meta-analysis, we searched Medline and Embase from database inception until March 6, 2022, using search terms including but not limited to "non-alcoholic fatty liver disease", "overweight", "obesity", and "prevalence". Cross-sectional and longitudinal observational studies published after Jan 1, 2000, written in or translated into English were eligible for inclusion; paediatric studies were excluded. Articles were included if the number of NAFLD, NAFL, or NASH events in an overweight and obese population could be extracted. Summary data were extracted from published reports. The primary outcomes were the prevalence of NAFLD, NAFL, and NASH in an overweight and obese population and the prevalence of fibrosis in individuals who were overweight or obese and who had NAFLD. A meta-analysis of proportions was done with the generalised linear mixed model. This study is registered with PROSPERO (CRD42022344526).

FINDINGS

The search identified 7389 articles. 151 studies met the inclusion criteria and were included in the meta-analysis. In the pooled analysis comprising 101 028 individuals, the prevalence of NAFLD in the overweight population was 69·99% (95% CI 65·40-74·21 I²=99·10%), the prevalence of NAFL was 42·49% (32·55-53·08, I²=96·40%), and the prevalence of NASH was 33·50% (28·38-39·04, I²=95·60%). Similar prevalence estimates were reported in the obese population for NAFLD (75·27% [95% CI 70·90-79·18]; I²=98·50%), NAFL (43·05% [32·78-53·97]; I²=96·30%) and NASH (33·67% [28·45-39·31]; I²=95·60%). The prevalence of NAFLD in the overweight population was the highest in the region of the Americas (75·34% [95% CI: 67·31-81·93]; I²=99·00%). Clinically significant fibrosis (stages F2-4) was present in 20·27% (95% CI 11·32-33·62; I²= 93·00%) of overweight individuals with NAFLD and in 21·60% (11·47-36·92; I²=95·00%) of obese patients with NAFLD while 6·65% (4·35-10·01; I²=58·00%) of overweight individuals with NAFLD and 6·85% (3·85-11·90; I²=90·00%) of obese individuals with NAFLD had advanced fibrosis (stages F3-4).

INTERPRETATION

This study summarises the estimated global prevalence of NAFLD, NAFL, and NASH in overweight and obese individuals; these findings are important for improving the understanding of the global NAFLD burden and supporting disease management in the at-risk overweight and obese population.

FUNDING

None.

Individual and environmental correlates of childhood maltreatment and exposure to community violence: Utilizing a latent profile and a multilevel meta-analytic approach

BACKGROUND

Childhood maltreatment (CM) and exposure to community violence (ETV) are correlated with physical/mental health and psychosocial problems. Typically, CM and ETV are examined separately, by subtypes within category, or collapsed across both into one category of adversity. Consequently, research is limited in identifying subgroups of individuals with different amounts of exposure to both CM and ETV. Accordingly, we lack sufficient understanding of the extent to which problems associated with CM and ETV vary based on the amount (i.e. dose) of exposure to both of these experiences.

METHODS

We used 20 samples (28,300 individuals) to estimate person-centered profiles of CM and ETV occurrence and co-occurrence within each sample. An individual data multilevel meta-analytic framework was used to determine the average effect size across samples for different profiles and conditional probability correlations within sociodemographic, neighborhood, health, mental health, and psychosocial domains.

RESULTS

The profile characterized by high levels of CM and high levels of ETV correlated with stressful life events, depression and anxiety symptoms, and general indicators of externalizing behaviors. CM predominant profiles were associated with mental health diagnoses and treatment. ETV predominant profiles associated with risk-taking/violent behavior and neighborhood-level disadvantage. However, nuance based on the dose of CM or ETV was evident.

CONCLUSIONS

It is important to identify subgroups based on the amount of exposure to CM and ETV. These subgroups have differential relationships with correlates across domains. Greater delineation and description of the lived experience will allow for more precision in addressing the burden of childhood adversity.

Prevalence of brucellosis in livestock of African and Asian continents: A systematic review and meta-analysis

Brucellosis is a highly contagious bacterial disease that mainly affects ruminants, but it may affect equines, canines, and felines. The disease is of utmost significance from an economic standpoint in countries where there is no national brucellosis prevention and eradication policy in operation. A systematic review was done to estimate disease burden, incidences, prevalence, and geographical distribution critical in planning appropriate intervention strategies for the control and prevention of Brucellosis. Research articles that were published during the period 2000–2020 were considered for this study after reinforced scrutiny by two independent authors. Meta-regression was used to examine heterogeneity, and subgroup and sensitivity analyses were used to calculate residual heterogeneity and the pooled prevalence of Brucellosis in livestock. Confounders such as geography, a diagnostic test, and species had the greatest R2 values of 17.8, 8.8, and 2.3%, respectively, indicating the presence of heterogeneity and necessitating more research into sensitivity and subgroup analysis. The combined pooled prevalence of brucellosis in both Asia and African countries was 8% when compared to 12% in the Indian livestock population. The findings of our systematic review and meta-analysis indicate that brucellosis continues to be an important animal and public health concern in developing countries of Asia and Africa, as evidenced by the prevalence rate of brucellosis in these regions. Our findings suggested that well-planned epidemiological surveillance studies in different geographic settings are needed to generate reliable data on disease burden including the economic loss in Asian and African countries.

Assessment of pharmacokinetic linearity after repeated drug administration

The prediction of drug concentration time courses after different dosing scenarios is greatly facilitated if the pharmacokinetics (PK) can be assumed linear. The assumption of linear PK thus needs careful evaluation for any new drug in development. Under linear PK, exposure is proportional to dose (linear PK across doses) and exposure at steady state can be predicted from a single dose based on the superposition principle (linear PK over time). While investigation of dose-proportionality is common practice, evaluation of time dependent PK has received less attention in the literature. In particular, the superposition principle can be used to assess whether the observed extent of accumulation after repeated administration is expected under the premise of linear PK. This work emphasizes the importance of the time related aspect of linear PK by introducing the predictability ratio (PR). Linear PK over time can be concluded if PR = 1. Accumulation is higher than expected if PR >1, and lower if PR <1. If PK data from multiple dose cohorts are available, the PR is assessed for each dose cohort and a supportive hypothesis test can be applied to test for potential differences between doses in PR.

No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis

BACKGROUND

The most commonly used techniques for elbow ulnar collateral ligament reconstruction (UCLR) are the docking and modified Jobe figure-of-8 techniques. Previous literature has suggested that UCLR with the docking technique is associated with fewer complications; however, these studies included results from the original classic Jobe technique without controlling for the effects of flexor pronator mass (FPM) detachment and routine submuscular ulnar nerve transposition (UNT).

PURPOSE/HYPOTHESIS

This study sought to compare the rates of complications and subsequent unplanned surgical procedures between the docking and figure-of-8 techniques. We hypothesized that there would be no significant difference in the rates of complications or subsequent unplanned surgical procedures between the techniques when the FPM was preserved and no routine submuscular UNT was performed.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A series of mixed-effects multivariate metaregression models were implemented using the restricted maximum likelihood method. Complications and subsequent unplanned surgical procedures were modeled as Freeman-Tukey transformed incidence rates for variance stabilization, and nerve-specific complications were assessed as the Freeman-Tukey transformed proportion of cases, with back-transformation to estimate summary effects.

RESULTS

There were 19 studies eligible for qualitative analysis, consisting of 1788 cases of UCLR (303 docking, 1485 figure-of-8), 18 of which were suitable for quantitative analysis (1769 cases; 291 docking, 1478 figure-of-8). A total of 338 complications were reported (17 for docking, 321 for figure-of-8), the majority of which were nerve related. Additionally, a total of 75 subsequent unplanned surgical procedures were related to the index UCLR procedure. There was no significant difference in the rate of complications (P = .146) or proportion of cases with nerve-specific complications (P = .127) between the docking and figure-of-8 techniques when controlling for FPM preservation versus detachment with submuscular UNT. FPM detachment with submuscular UNT was independently associated with a significantly higher proportion of postoperative nerve-related complications (P = .004). There was also no significant difference in the rates of subsequent unplanned surgical procedures between the docking and figure-of-8 techniques (P = .961), although FPM detachment with routine submuscular UNT was independently associated with a significantly higher incidence of subsequent unplanned surgical procedures.

CONCLUSION

The results of this study demonstrate no significant difference in the rates of complications or subsequent unplanned surgical procedures between the figure-of-8 and docking techniques for UCLR when controlling for FPM preservation versus detachment with submuscular UNT. With modern muscle-sparing approaches and avoiding submuscular UNT, the modified Jobe technique does not differ significantly from the docking technique in terms of complication rates, proportions of cases with nerve-specific complications, or rates of subsequent unplanned surgical procedures.

Major bat-borne zoonotic viral epidemics in Asia and Africa: A systematic review and meta-analysis

Bats are the natural reservoir host for many pathogenic and non‐pathogenic viruses, potentially spilling over to humans and domestic animals directly or via an intermediate host. The ongoing COVID‐19 pandemic is the continuation of virus spillover events that have taken place over the last few decades, particularly in Asia and Africa. Therefore, these bat‐associated epidemics provide a significant number of hints, including respiratory cellular tropism, more intense susceptibility to these cell types, and overall likely to become a pandemic for the next spillover. In this systematic review, we analysed data to insight, through bat‐originated spillover in Asia and Africa. We used STATA/IC‐13 software for descriptive statistics and meta‐analysis. The random effect of meta‐analysis showed that the pooled estimates of case fatality rates of bat‐originated viral zoonotic diseases were higher in Africa (61.06%, 95%CI: 50.26 to 71.85, l²% = 97.3, p < 0.001). Moreover, estimates of case fatality rates were higher in Ebola (61.06%; 95%CI: 50.26 to 71.85, l²% = 97.3, p < 0.001) followed by Nipah (55.19%; 95%CI: 39.29 to 71.09, l²% = 94.2, p < 0.001), MERS (18.49%; 95%CI: 8.19 to 28.76, l²% = 95.4, p < 0.001) and SARS (10.86%; 95%CI: 6.02 to 15.71, l²% = 85.7, p < 0.001) with the overall case fatality rates of 29.86 (95%CI: 29.97 to 48.58, l²% = 99.0, p < 0.001). Bat‐originated viruses have caused several outbreaks of deadly diseases, including Nipah, Ebola, SARS and MERS in Asia and Africa in a sequential fashion. Nipah virus emerged first in Malaysia, but later, periodic outbreaks were noticed in Bangladesh and India. Similarly, the Ebola virus was detected in the African continent with neurological disorders in humans, like Nipah, seen in the Asian region. Two important coronaviruses, MERS and SARS, were introduced, both with the potential to infect respiratory passages. This paper explores the dimension of spillover events within and/or between bat–human and the epidemiological risk factors, which may lead to another pandemic occurring. Further, these processes enhance the bat‐originated virus, which utilises an intermediate host to jump into human species.

Application of Nd:YAG laser to the anterior vitreous in malignant glaucoma - a systemic review and meta-analysis

PURPOSE

The study aims to review the efficacy, safety, and technique of Nd:YAG laser vitreolysis for the management of malignant glaucoma (MG).

METHODS

We performed a search of electronic databases for all published studies which included technical specifications of Nd:YAG laser application for MG. Individual patient data was extracted and evaluated in a weighted pooled analysis.

RESULTS

Thirty eyes were reported on from seven studies worldwide. Age of affected patients ranged between 37 and 82 years. Nd:YAG vitreolysis was performed either through an iritodomy (66.7%, 18/27 eyes), transpupillary (18.5%, 5/27 eyes), or through both simultaneously (14.8%, 4/27 eyes). Treatment intensity ranged between 1.0 and 11.00 mJ with 75.9% (22/29 eyes) of treatments being 3.0 mJ or lower. Between 1 and 41 pulses per session were applied. Rates of both anatomical and intraocular pressure resolution were examined. Overall, in a pooled analysis, 77% of eyes demonstrated MG resolution with no further treatment required after Nd:YAG vitreolysis (95% CI: 58.1 to 91.4%). A trend for lower need of additional interventions was seen with transpupillary application (11.1% versus 42.1%). No complications were reported.

CONCLUSIONS

Nd:YAG laser vitreolysis is a safe procedure, associated with MG resolution in the majority of reported cases, regardless of treatment intensity. Transpupillary treatment may be associated with lower risk of re-intervention.

Meta-Analysis of Randomized Clinical Trials Evaluating Effectiveness of a Multivitamin Supplementation against Oxidative Stress in Healthy Subjects

A meta-analysis has been widely applied to draw general conclusions using a set of studies with similar purposes and designs. This study aimed to perform a meta-analysis of six randomized placebo-controlled trials, independently conducted for the relationship between a plant-based multivitamin/mineral supplementation (PMS) and oxidative stress for 6 to 8 weeks, to provide overall estimates of those effects. In detail, linear mixed model analysis was first conducted on each study to obtain individual estimates; then, two types of meta-analysis were applied to combine the individual estimates from all available studies (overall meta-analysis) and region-specific studies (subgroup meta-analysis). In the meta-analysis, we selected 19 biomarker variables that overlapped in at least two studies and found 6 variables significant in at least one meta-analysis. The overall estimates of beta coefficients were 0.17 for vitamin C, 0.80 for vitamin B₆, 0.46 for vitamin B₁₂, 0.81 for folate, 0.36 for β-carotene, and -0.17 for oxidized LDL (ox-LDL). Subsequent association analysis revealed significant negative correlations between plasma free radical scavenging nutrients and plasma ox-LDL levels, indicating a general benefit of PMS in alleviating oxidative stress by providing exogenous oxidant scavengers.

Lung Cancer Computational Biology and Resources

Comprehensive clinical, pathological, and molecular data, when appropriately integrated with advanced computational approaches, are transforming the way we characterize and study lung cancer. Clinically, cancer registry and publicly available historical clinical trial data enable retrospective analyses to examine how socioeconomic factors, patient demographics, and cancer characteristics affect treatment and outcome. Pathologically, digital pathology and artificial intelligence are revolutionizing histopathological image analyses, not only with improved efficiency and accuracy, but also by extracting additional information for prognostication and tumor microenvironment characterization. Genetically and molecularly, individual patient tumors and preclinical models of lung cancer are profiled by various high-throughput platforms to characterize the molecular properties and functional liabilities. The resulting multi-omics data sets and their interrogation facilitate both basic research mechanistic studies and translation of the findings into the clinic. In this review, we provide a list of resources and tools potentially valuable for lung cancer basic and translational research. Importantly, we point out pitfalls and caveats when performing computational analyses of these data sets and provide a vision of future computational biology developments that will aid lung cancer translational research.

Dietary Intake and Biomarkers of α-Linolenic Acid and Mortality: A Meta-Analysis of Prospective Cohort Studies

Background: The association between α-linolenic acid (ALA) and mortality is inconsistent and has not been summarized systematically.

Objective: The purpose was to conduct a meta-analysis that synthesized the results of prospective cohort studies to investigate associations between ALA intake and mortality.

Methods: We conducted a comprehensive search on PubMed, Embase, and Web of Science databases on May 1, 2021, for relevant prospective cohort studies which reported associations of ALA (assessed by dietary surveys and/or ALA concentrations in body tissues) with mortality from all-cause, cardiovascular disease (CVD), and other diseases. Multivariable-adjusted relative risks (RRs) were pooled by a random or fixed-effects model.

Results: A total of 34 prospective cohort studies, of which 17 reported dietary ALA intake, 14 for ALA biomarkers, and the remaining 3 reported both of intake and biomarkers. The studies included 6,58,634 participants, and deaths were classified into all-cause mortality (56,898), CVD mortality (19,123), and other diseases mortality (19,061). Pooled RRs of ALA intake were 0.93 (95% CI: 0.86, 1.01, I² = 71.2%) for all-cause mortality, 0.90 (95% CI: 0.83, 0.98, I² = 22.1%) for CVD mortality, and 0.94 (95% CI: 0.83, 1.06, I² = 73.3%) for other diseases mortality. The two-stage random-effects dose-response analysis showed a linear relationship between dietary ALA intake and CVD-mortality and each 0.5% energy increment of ALA intake was associated with a 5% lower risk of CVD-mortality (RR: 0.95; 95% CI: 0.90, 1.00). Pooled RRs per SD increment of ALA biomarkers were 0.99 (95% CI: 0.96, 1.01, I² = 27%) for all-cause mortality, 1.00 (95% CI: 0.98, 1.03, I² = 0%) for CVD mortality and 0.98 (95% CI: 0.95, 1.01, I² = 0%) for other diseases mortality.

Conclusions: This meta-analysis summarizing the available prospective cohort studies indicated that ALA intake was associated with reduced risk of mortality, especially CVD mortality. Our findings suggest that ALA consumption may be beneficial for death prevention. Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO; identifier: CRD42021264532.

Survival of dental implants and occurrence of osteoradionecrosis in irradiated head and neck cancer patients: a systematic review and meta-analysis

OBJECTIVES

This systematic review assesses dental implant survival, calculates the incidence rate of osteoradionecrosis, and evaluates risk factors in irradiated head and neck cancer patients.

MATERIALS AND METHODS

Various databases (e.g., Medline/Embase using Ovid) and gray literature platforms were searched using a combination of keywords and subject headings. When appropriate, meta-analysis was carried out using a random effects model. Otherwise, pooled analysis was applied.

RESULTS

A total of 425 of the 660 included patients received radiotherapy. In total, 2602 dental implants were placed, and 1637 were placed in irradiated patients. Implant survival after an average follow-up of 37.7 months was 97% (5% confidence interval, CI 95.2%, 95% CI 98.3%) in nonirradiated patients and 91.9% (5% CI 87.7%, 95% CI: 95.3%) after an average follow-up of 39.8 months in irradiated patients. Osteoradionecrosis occurred in 11 cases, leading to an incidence of 3% (5% CI 1.6%, 95% CI 4.9%). The main factors impacting implant survival were radiation and grafting status, while factors influencing osteoradionecrosis could not be determined using meta-analysis.

CONCLUSION

Our data show that implant survival in irradiated patients is lower than in nonirradiated patients, and osteoradionecrosis is-while rare-a serious complication that any OMF surgeon should be prepared for. The key to success could be a standardized patient selection and therapy to improve the standard of care, reduce risks and shorten treatment time.

CLINICAL RELEVANCE

Our analysis provides further evidence that implant placement is a feasible treatment option in irradiated head and neck cancer patients with diminished oral function and good long-term cancer prognosis.

Determinants of exclusive breast-feeding discontinuation in southeastern Brazil, 2008-2013: a pooled data analysis

OBJECTIVE

To analyse the determinants of exclusive breast-feeding (EBF) discontinuation in southeastern Brazil between 2008 and 2013.

DESIGN

Secondary cross-sectional data were analysed from three waves of child feeding surveys conducted in the city of Marília, São Paulo, Brazil, in 2008, 2011 and 2013 (n 1645 children under 6 months). Multivariable Poisson regression models were used to test the association between EBF discontinuation and socio-economic, demographic and biomedical factors in a pooled sample and within each survey wave.

SETTING

Regionally representative cross-sectional survey from Brazil.

PARTICIPANTS

The analytical sample included 1645 infants under 6 months old.

RESULTS

In the pooled sample, 40·7 % of the infants were exclusively breastfed. Between 2008 and 2013, there was a significant increase in C-section (35·1-42·7 %) and pacifier use (41·4-48·8 %). The determinants of EBF discontinuation in the pooled analysis were mothers working outside the home (adjusted prevalence ratio (APR) = 1·10; 95 % CI 1·00, 1·21), first-time mothers (APR = 1·10; 95 % CI 1·01, 1·20), pacifier use (APR = 1·48; 95 % CI 1·36, 1·61) and low birth weight (APR = 1·17; 95 % CI 1·05, 1·32).

CONCLUSIONS

Mothers working outside the home, first-time moms, pacifier use and low birth weight were the factors associated with EBF discontinuation. Evidence-based counselling strategies during antenatal and early postpartum care in primary healthcare are needed to address the modifiable determinants of EBF discontinuation and ultimately to improve its rates in southeastern Brazil.

The association of impaired lung function and nonalcoholic fatty liver disease: a systematic review

BACKGROUND AND AIMS

Nonalcoholic fatty liver disease (NAFLD) and impaired lung function share similar risk factors and phenotypes, such as obesity and type 2 diabetes. The study is an updated meta-analysis to evaluate the association between NAFLD and impaired lung function.

METHODS

A total of 696 articles were identified with mention of NAFLD and lung function (or pulmonary function testing) in MEDLINE, EMBASE, and Scopus. After de-duplication, 455 articles were screened, 18 underwent full-text review. Five studies met our review and inclusion criteria with an interrater reliability kappa score of 1.

RESULTS

Five studies with a total of 118 118 subjects (28.4% with NAFLD) were included. The cross-sectional studies supported a statistically significant relationship between decreased pulmonary function tests and NAFLD. There was no association observed with obstructive lung pattern. One of the longitudinal studies revealed an association with increased rate of decline in forced vital capacity in patients with NAFLD and FIB4 score ≥1.30 (-21.7 vs. -27.4 mL/year, P = 0.001 in males, -22.4 vs. -27.9 mL/year, P = 0.016 in females). The second longitudinal study revealed that patients with impaired pulmonary function had an increased hazard ratio of developing NAFLD dependent on the severity of pulmonary impairment.

CONCLUSIONS

This is the first systematic review that supports an association of NAFLD with decreased (restrictive) lung function. The estimated severity of liver fibrosis correlates with the rate of progression of restrictive lung function. There are also data showing that patients with impaired lung function have a higher risk of developing NAFLD.

Porcine Xenograft and Epidermal Fully Synthetic Skin Substitutes in the Treatment of Partial-Thickness Burns: A Literature Review

Background and Objectives: Porcine xenografts have been used successfully in partial thickness burn treatment for many years. Their disappearance from the market led to the search for effective and efficient alternatives. In this article, we examine the synthetic epidermal skin substitute Suprathel^® as a substitute in the treatment of partial thickness burns. Materials and Methods: A systematic review following the PRISMA guidelines has been performed. Sixteen Suprathel^® and 12 porcine xenograft studies could be included. Advantages and disadvantages between the treatments and the studies’ primary endpoints have been investigated qualitatively and quantitatively. Results: Although Suprathel had a nearly six times larger TBSA in their studies (p < 0.001), it showed a significantly lower necessity for skin grafts (p < 0.001), and we found a significantly lower infection rate (p < 0.001) than in Porcine Xenografts. Nonetheless, no significant differences in the healing time (p = 0.67) and the number of dressing changes until complete wound healing (p = 0.139) could be found. Both products reduced pain to various degrees with the impression of a better performance of Suprathel^® on a qualitative level. Porcine xenograft was not recommended for donor sites or coverage of sheet-transplanted keratinocytes, while Suprathel^® was used successfully in both indications. Conclusion: The investigated parameters indicate that Suprathel^® to be an effective replacement for porcine xenografts with even lower subsequent treatment rates. Suprathel^® appears to be usable in an extended range of indications compared to porcine xenograft. Data heterogeneity limited conclusions from the results.

Lung cancer risk in painters: results from the SYNERGY pooled case-control study consortium

OBJECTIVES

We evaluated the risk of lung cancer associated with ever working as a painter, duration of employment and type of painter by histological subtype as well as joint effects with smoking, within the SYNERGY project.

METHODS

Data were pooled from 16 participating case-control studies conducted internationally. Detailed individual occupational and smoking histories were available for 19 369 lung cancer cases (684 ever employed as painters) and 23 674 age-matched and sex-matched controls (532 painters). Multivariable unconditional logistic regression models were adjusted for age, sex, centre, cigarette pack-years, time-since-smoking cessation and lifetime work in other jobs that entailed exposure to lung carcinogens.

RESULTS

Ever having worked as a painter was associated with an increased risk of lung cancer in men (OR 1.30; 95% CI 1.13 to 1.50). The association was strongest for construction and repair painters and the risk was elevated for all histological subtypes, although more evident for small cell and squamous cell lung cancer than for adenocarcinoma and large cell carcinoma. There was evidence of interaction on the additive scale between smoking and employment as a painter (relative excess risk due to interaction >0).

CONCLUSIONS

Our results by type/industry of painter may aid future identification of causative agents or exposure scenarios to develop evidence-based practices for reducing harmful exposures in painters.

Benefit of Oxaliplatin in Stage III Colon Cancer According to IDEA Risk Groups: Findings from the ACCENT Database of 4934 Patients

BACKGROUND

The International Duration Evaluation of Adjuvant Chemotherapy (IDEA) pooled analysis compared 3 to 6 months of adjuvant chemotherapy for stage III colon cancer. Patients were classified into low risk and high risk, suggesting low-risk patients may be offered only 3 months of treatment. In this study, we aimed to assess the benefit of oxaliplatin in the adjuvant setting per IDEA risk groups, using data from 3 large adjuvant phase III studies, namely Multicenter International Study of Oxaliplatin/Fluorouracil/ Leucovorin in the Adjuvant Treatment of Colon Cancer (MOSAIC), C-07, and XELOXA.

METHODS

Using the MOSAIC, C-07, and XELOXA previously published studies, we identified 2810 low-risk and 2124 high-risk patients with stage III colon cancer. We used Cox regression model to evaluate the magnitude of survival differences between IDEA risk groups, according to oxaliplatin use. Based on design similarity and equivalent follow-up data, MOSAIC and C-07 were pooled, whereas XELOXA was analyzed separately. Subgroup analyses were also performed for T4 and/or N2 patients.

RESULTS

Individuals with IDEA low and high risk derived overall survival benefit from the addition of oxaliplatin to adjuvant chemotherapy, with adjusted hazard ratios of 0.79 (0.66-0.95) and 0.84 (0.71-0.99), respectively. Among individuals with IDEA high risk, those with T4 disease did not gain overall survival benefit from addition of oxaliplatin with hazard ratio of 0.95 (0.71-1.27). Similar results were demonstrated using data from the XELOXA study.

CONCLUSION

IDEA risk classification per se does not predict benefit from addition of oxaliplatin to adjuvant chemotherapy in stage III colon cancer. T4 disease may predict lack of benefit from oxaliplatin addition.

Effect of intensive blood pressure on the progression of non-diabetic chronic kidney disease at varying degrees of proteinuria

The ideal blood pressure (BP) target for renoprotection is uncertain in patients with non-diabetic chronic kidney disease (CKD), especially considering the influence exerted by pre-existing proteinuria. In this pooled analysis of landmark trials, we coalesced individual data from 5001 such subjects randomized to intensive versus standard BP targets. We employed multivariable regression to evaluate the relationship between follow-up systolic blood pressure (SBP) and diastolic blood pressure (DBP) on CKD progression (defined as glomerular filtration rate decline by 50% or end-stage renal disease), focusing on the potential for effect modification by baseline proteinuria or albuminuria. The median follow-up was 3.2 years. We found that SBP rather than DBP was the primary predictor of renal outcomes. The optimal SBP target was 110-129 mm Hg. We observed a strong interaction between SBP and proteinuria such that lower SBP ranges were significantly linked with progressively lower CKD risk in grade A3 albuminuria or ≥0.5-1 g/day proteinuria (relative to SBP 110-119 mm Hg, the adjusted HR for SBP 120-129 mm Hg, 130-139 mm Hg, and 140-149 mm Hg was 1.5, 2.3, and 3.3, respectively; all p<0.05). In grade A2 microalbuminuria or proteinuria near 0.5 g/day, a non-significant but possible connection was seen between tighter BP and decreased CKD (aforementioned HRs all <2; all p>0.05), while in grade A1 albuminuria or proteinuria <0.2 g/day no significant association was apparent (HRs all <1.5; all p>0.1). We conclude that in non-diabetic CKD, stricter BP targets <130 mm Hg may help limit CKD progression as proteinuria rises.

Meta-analysis of tumor- and T cell-intrinsic mechanisms of sensitization to checkpoint inhibition

Checkpoint inhibitors (CPIs) augment adaptive immunity. Systematic pan-tumor analyses may reveal the relative importance of tumor-cell-intrinsic and microenvironmental features underpinning CPI sensitization. Here, we collated whole-exome and transcriptomic data for >1,000 CPI-treated patients across seven tumor types, utilizing standardized bioinformatics workflows and clinical outcome criteria to validate multivariable predictors of CPI sensitization. Clonal tumor mutation burden (TMB) was the strongest predictor of CPI response, followed by total TMB and CXCL9 expression. Subclonal TMB, somatic copy alteration burden, and histocompatibility leukocyte antigen (HLA) evolutionary divergence failed to attain pan-cancer significance. Dinucleotide variants were identified as a source of immunogenic epitopes associated with radical amino acid substitutions and enhanced peptide hydrophobicity/immunogenicity. Copy-number analysis revealed two additional determinants of CPI outcome supported by prior functional evidence: 9q34 (TRAF2) loss associated with response and CCND1 amplification associated with resistance. Finally, single-cell RNA sequencing (RNA-seq) of clonal neoantigen-reactive CD8 tumor-infiltrating lymphocytes (TILs), combined with bulk RNA-seq analysis of CPI-responding tumors, identified CCR5 and CXCL13 as T-cell-intrinsic markers of CPI sensitivity.

Reduced risk of COVID-19 hospitalization in asthmatic and COPD patients: a benefit of inhaled corticosteroids?

Background: The comorbidities and clinical signs of coronavirus disease 2019 (COVID-19) patients have been reported mainly as descriptive statistics, rather than quantitative analysis even in very large investigations. The aim of this study was to identify specific patients’ characteristics that may modulate COVID-19 hospitalization risk.

Research design and methods: A pooled analysis was performed on high-quality epidemiological studies to quantify the prevalence (%) of comorbidities and clinical signs in hospitalized COVID-19 patients. Pooled data were used to calculate the relative risk (RR) of specific comorbidities by matching the frequency of comorbidities in hospitalized COVID-19 patients with those of general population.

Results: The most frequent comorbidities were hypertension, diabetes mellitus, and cardiovascular and/or cerebrovascular diseases. The RR of COVID-19 hospitalization was significantly (P < 0.05) reduced in patients with asthma (0.86, 0.77–0.97) or chronic obstructive pulmonary disease (COPD) (0.46, 0.40–0.52). The most frequent clinical signs were fever and cough.

Conclusion: The clinical signs of hospitalized COVID-19 patients are similar to those of other infective diseases. Patients with asthma or COPD were at lower hospitalization risk. This paradoxical evidence could be related with the protective effect of inhaled corticosteroids that are administered worldwide to most asthmatic and COPD patients.

People with obsessive-compulsive disorder often remain symptomatic following psychological treatment: A clinical significance analysis of manualised psychological interventions

BACKGROUND

Previous meta-analyses conclude that efficacious psychological treatments for obsessive-compulsive disorder (OCD) exist. However, determining the efficacy of psychological treatments requires multiple forms of assessment. We conducted an individual patient data meta-analysis of randomised controlled trials (RCTs) of manualised psychological therapy for adults with OCD.

METHODS

Four electronic databases were searched from their inception until July 2019. IPD were available for 24 (n = 1626) of 43 (n = 2455) eligible RCTs. Treatment efficacy was evaluated using clinical significance analyses (using standardised Jacobson methodology) and standardised mean difference within-group effect-size analyses. Outcomes were Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores at post-treatment and follow-up.

RESULTS

At follow-up, large within-group effect sizes were found for treated patients (g = 1.45) and controls (g = 0.90). Treated patients were significantly more likely than controls to recover, but recovery rates were low; post-intervention, only 32% of treated patients and 3% of controls recovered; rising to 38% and 21% respectively at follow-up. Regardless of allocation, only 20% of patients were asymptomatic at follow-up. Individual cognitive therapy (CT) was most efficacious, followed by group CT plus exposure and response prevention. Self-help interventions were generally less efficacious than face-to-face approaches.

LIMITATIONS

Data were analysed from 24 of the 43 eligible RCTs. We were unable to consider the long-term efficacy of treatments because only two RCTs provided long-term (> 12 month) follow-up data.

CONCLUSION

Almost 80% of treated patients remain symptomatic. The efficacy of psychological interventions for patients with OCD must be enhanced.

Normative values of cervical range of motion for both children and adults: A systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To synthesize studies reporting normative values of active cervical range of motion (ROM) in healthy children and adults.

SUMMARY OF BACKGROUND DATA

Evaluating active cervical ROM is part of routine assessment of patients with neck pain. Interpretation of outcomes necessitates having normative data per age category. Currently available normative values differ across studies, perhaps due to (the measurement properties of) the devices used.

METHODS

A systematic review according to PRISMA guidelines was conducted. Electronic searches included EMBASE, MEDLINE, Web of Science, Cochrane, CINAHL and Google Scholar databases from inception to August 2018. Included studies had to involve healthy subjects in which active cervical ROM was assessed or when determining normative values was the aim of the study. Methodological quality of the included studies was assessed using an adapted version of the QUADAS. A mean value was re-calculated for the total group in case data were presented per gender per age-category only. When possible, data were pooled.

RESULTS

From 2151 unique hits, 217 articles were selected for full text assessment, after which 162 articles were excluded. Data were extracted from 55 articles using 16 different measurement devices. Twenty-five studies were rated as being of "low risk of bias". Only data from studies evaluating the CROM device and Zebris could be pooled.

CONCLUSIONS

This systematic review revealed that although a large number of studies assessed normative data for active cervical ROM, the methodological quality of most studies was low and the heterogeneity between studies was high. Only the normative data for active cervical ROM using the CROM device seems to be useful. Overall, reference values for measuring active cervical ROM is unclear for most measurement devices. Normative values of cervical range of motion for both children and adults: a systematic review.

Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis

Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.

Meta-Analyses in Plastic Surgery: Can We Trust Their Results?

BACKGROUND

Meta-analyses are common in the plastic surgery literature, but studies concerning their quality are lacking. The authors assessed the overall quality of meta-analyses in plastic surgery, and attempted to identify variables associated with scientific quality.

METHODS

A systematic review of meta-analyses published in seven plastic surgery journals between 2007 and 2017 was undertaken. Publication descriptors and methodologic details were extracted. Articles were assessed using the following two instruments: A Measurement Tool to Assess Systematic Reviews (AMSTAR) and AMSTAR 2.

RESULTS

Seventy-four studies were included. The number of meta-analyses per year increased. Most meta-analyses assessed a single intervention (59.5 percent), and pooled a mean of 20.9 studies (range, two to 134), including a mean of 2463 patients (range, 44 to 14,884). Most meta-analyses were published in Plastic and Reconstructive Surgery (44.6 percent) and included midlevel evidence (II to IV) primary studies. Only 16.2 percent of meta-analyses included randomized controlled trials. Meta-analyses generally reported positive (81.1 percent) and significant results (77.0 percent). Median AMSTAR score was 7 of 11 (interquartile range, 5 to 8). Higher AMSTAR scores correlated with more recent meta-analyses that provided a rationale for statistical pooling, and appropriately managed methodologic heterogeneity (r = 0.66; p < 0.01).

CONCLUSIONS

Despite an increase in number and quality, meta-analyses are at high risk of bias because of the low level of evidence of included primary studies and heterogeneity within and between primary studies. Plastic surgeons should be aware of the pitfalls of conducting and interpreting meta-analyses.

Effects of Radiotherapy in Early-Stage, Low-Recurrence Risk, Hormone-Sensitive Breast Cancer

Background

Radiotherapy after breast conservation has become the standard of care. Prior meta-analyses on effects of radiotherapy predated availability of gene expression profiling (GEP) to assess recurrence risk and/or did not include all relevant outcomes. This analysis used GEP information with pooled individual-level data to evaluate the impact of omitting radiotherapy on recurrence and mortality.

Methods

We considered trials that evaluated or administered radiotherapy after lumpectomy in women with low-risk breast cancer. Women included had undergone lumpectomy and were treated with hormonal therapy for stage I, ER+ and/or PR+, HER2- breast cancer with Oncotype scores no greater than 18. Recurrence-free interval (RFI), type of RFI (locoregional or distant), and breast cancer-specific and overall survival were compared between no radiotherapy and radiotherapy using adjusted Cox models. All statistical tests were two-sided.

Results

The final sample included 1778 women from seven trials. Omission of radiotherapy was associated with an overall adjusted hazard ratio of 2.59 (95% confidence interval [CI] = 1.38 to 4.89, P = .003) for RFI. There was a statistically significant increase in any first locoregional recurrence (P = .001), but not distant recurrence events (P = .90), or breast cancer-specific (P = .85) or overall survival (P = .61). Five-year RFI rate was high (93.5% for no radiotherapy vs 97.9% for radiotherapy; absolute reduction = 4.4%, 95% CI = 0.7% to 8.1%, P = .03). The effects of radiotherapy varied across subgroups, with lower RFI rates for those with Oncotype scores of less than 11 (vs 11-18), older (vs younger), and ER+/PR+ status (vs other).

Conclusions

Omission of radiotherapy in hormone-sensitive patients with low recurrence risk may lead to a modest increase in locoregional recurrence event rates, but does not appear to increase the rate of distant recurrence or death.

Urinary bisphenol A and serum lipids: a meta-analysis of six NHANES examination cycles (2003-2014)

Background

Mounting evidence from both experimental and epidemiological studies suggest that exposure to the endocrine disruptor bisphenol A (BPA) has a role in metabolic disorders. The aim of the present study was to assess whether urinary BPA concentrations were associated with dyslipidaemia in children (≤17 years old) and adults (≥18 years old) by performing a meta-analysis of data from six cycles (2003–2014) in the National Health and Nutrition Examination Survey (NHANES).

Methods

We conducted a meta-analysis of data from 4604 children and 10 989 adult participants who were part of a substudy of urinary BPA measurements from six NHANES cycles from 2003 to 2014. Linear regression models conducted in each cycle were used to perform a meta-analysis to investigate associations between urinary BPA and serum levels of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), triglycerides (TG) and apolipoprotein B (ApoB).

Results

The meta-analysis did not disclose any significant associations between urinary BPA concentrations and LDL-C, HDL-C, TC, TG and ApoB in children. In adults, the meta-analysis revealed negative regression coefficients for all five lipid variables. However, no associations were significant following Bonferroni correction for multiple tests.

Conclusions

In the present meta-analysis of cross-sectional data from NHANES, no associations were found between urinary BPA and the five different lipid variables when investigated in both children and adults. However, considering the cross-sectional nature of the present study, results should be clarified in carefully designed longitudinal cohort studies with repeated BPA measurements.

Insomnia and cognitive performance: A systematic review and meta-analysis

Cognitive performance has been extensively investigated in relation to insomnia, yet review of the literature reveals discrepant findings. The current study aimed to synthesize this literature with a systematic review and meta-analysis. 48 studies (k = 50 independent samples, n = 4539 total participants) met inclusion criteria. Omnibus meta-analysis revealed insomnia was associated with poorer overall cognitive performance (Hedge's g = -0.24, p < 0.001). Analyses by cognitive domain revealed insomnia was specifically associated with impairments in subjective cognitive performance (g = -0.35), and objective measures of perceptual function (g = -0.24), manipulation (g = -0.52) and retention/capacity in working memory (g = -0.30), complex attention (g = -0.36), alertness (g = -0.14), episodic memory (g = -0.29), and problem solving in executive functions (g = -0.39). Age, percent female, publication year, and insomnia measure did not consistently moderate findings. Approximately 44% of studies failed to use diagnostic criteria when categorizing insomnia and cognitive measures varied widely. This indicates a need for standardization of methods assessing insomnia and cognitive performance in research. Overall, findings from this meta-analysis indicate insomnia is associated with impairment in objective and subjective cognitive performance, highlighting the utility of treating insomnia to potentially improve cognitive outcomes.

Sleep Duration and Sleep Quality in Caregivers of Patients With Dementia: A Systematic Review and Meta-analysis

IMPORTANCE

In the United States, 16 million family caregivers provide long-term care for patients with dementia. Although one's physical, mental, and cognitive health depends on sleep, many caregivers experience chronic stress, and stress is typically associated with worse sleep quantity and quality.

OBJECTIVE

To quantify the extent, nature, and treatability of sleep problems in dementia caregivers.

DATA SOURCES

PubMed and Scopus databases were systematically searched for articles published through June 2018 using the following keywords: caregiver or spouse or caretaker AND sleep or circadian AND dementia or Alzheimer. Backward citation tracking was performed, and corresponding authors were contacted for additional data to conduct meta-analyses and pooled analyses.

STUDY SELECTION

Two reviewers independently screened 805 studies to identify those that reported sleep duration or sleep quality in caregivers of patients with dementia.

DATA EXTRACTION AND SYNTHESIS

Following the PRISMA guidelines, 2 reviewers independently extracted data from all studies and conducted National Heart, Lung, and Blood Institute study quality assessments. Meta-analyses with random-effects models were performed to evaluate sleep duration, sleep quality, and sleep interventions in dementia caregivers.

MAIN OUTCOMES AND MEASURES

Sleep quality and total sleep time were measured by polysomnography, actigraphy, and self-report.

RESULTS

Thirty-five studies were analyzed with data from 3268 caregivers (pooled mean age [SD of sample means], 63.48 [5.99] years; 76.7% female) were analyzed. Relative to age-matched control noncaregiver adults, caregivers had lower sleep durations akin to losing 2.42 to 3.50 hours each week (Hedges g = -0.29; 95% CI, -0.48 to -0.09; P = .01). Sleep quality was significantly lower in caregivers (Hedges g = -0.66; 95% CI, -0.89 to -0.42; P < .001), but caregivers who underwent sleep intervention trials had better sleep quality than caregivers who did not receive a sleep intervention (Hedges g = 0.35; 95% CI, 0.20-0.49; P < .001).

CONCLUSIONS AND RELEVANCE

Sleep debt is known to have cumulative associations with physical, mental, and cognitive health; therefore, poor sleep quality in dementia caregivers should be recognized and addressed. Although the caregiving role is stressful and cognitively demanding by its nature, better sleep quality was observed in caregivers who received low-cost behavioral interventions.

Systematic Analysis of Gene Expression in Lung Adenocarcinoma and Squamous Cell Carcinoma with a Case Study of FAM83A and FAM83B

Introduction: In our previous study, we constructed a Lung Cancer Explorer (LCE) database housing lung cancer-specific expression data and clinical data from over 6700 patients in 56 studies. Methods: Using this dataset of the largest collection of lung cancer gene expression along with our meta-analysis method, we systematically interrogated the association between gene expression and overall survival as well as the expression difference between tumor and normal (adjacent non-malignant tissue) samples in lung adenocarcinoma (ADC) and lung squamous cell carcinoma (SQCC). A case study for FAM83A and FAM83B was performed as a demonstration for hypothesis testing with our database. Results: We showed that the reproducibility of results across studies varied by histological subtype and analysis type. Genes and pathways unique or common to the two histological subtypes were identified and the results were integrated into LCE to facilitate user exploration. In our case study, we verified the findings from a previous study on FAM83A and FAM83B in non-small cell lung cancer. Conclusions: This study used gene expression data from a large cohort of patients to explore the molecular differences between lung ADC and SQCC.

A genetic variant associated with multiple sclerosis inversely affects the expression of CD58 and microRNA-548ac from the same gene

Genome-wide association studies have identified more than 200 genetic variants to be associated with an increased risk of developing multiple sclerosis (MS). Still, little is known about the causal molecular mechanisms that underlie the genetic contribution to disease susceptibility. In this study, we investigated the role of the single-nucleotide polymorphism (SNP) rs1414273, which is located within the microRNA-548ac stem-loop sequence in the first intron of the CD58 gene. We conducted an expression quantitative trait locus (eQTL) analysis based on public RNA-sequencing and microarray data of blood-derived cells of more than 1000 subjects. Additionally, CD58 transcripts and mature hsa-miR-548ac molecules were measured using real-time PCR in peripheral blood samples of 32 MS patients. Cell culture experiments were performed to evaluate the efficiency of Drosha-mediated stem-loop processing dependent on genotype and to determine the target genes of this underexplored microRNA. Across different global populations and data sets, carriers of the MS risk allele showed reduced CD58 mRNA levels but increased hsa-miR-548ac levels. We provide evidence that the SNP rs1414273 might alter Drosha cleavage activity, thereby provoking partial uncoupling of CD58 gene expression and microRNA-548ac production from the shared primary transcript in immune cells. Moreover, the microRNA was found to regulate genes, which participate in inflammatory processes and in controlling the balance of protein folding and degradation. We thus uncovered new regulatory implications of the MS-associated haplotype of the CD58 gene locus, and we remind that paradoxical findings can be encountered in the analysis of eQTLs upon data aggregation. Our study illustrates that a better understanding of RNA processing events might help to establish the functional nature of genetic variants, which predispose to inflammatory and neurological diseases.

More than 200 genetic loci have been associated with an increased risk of developing multiple sclerosis (MS). Here, we investigated the role of a single-nucleotide polymorphism (SNP), which is located within the microRNA-548ac stem-loop sequence in the first intron of the CD58 gene. We analyzed expression data of blood-derived cells of about 1000 subjects and observed that MS risk allele carriers have reduced CD58 mRNA levels but increased hsa-miR-548ac levels. Our findings suggest that Drosha cleavage activity is affected, perhaps attributable to the specific SNP. This may contribute to partial uncoupling of CD58 gene expression and hsa-miR-548ac production from the shared primary transcript in immune cells. We discovered that the mature microRNA downregulates genes involved in inflammatory processes and in controlling the balance of protein folding and degradation. Our study exemplifies that paradoxical findings can be encountered in the analysis of genetic variants regulating transcription and/or RNA processing.

Community-based specialist palliative care teams and health system costs at end of life: a retrospective matched cohort study

BACKGROUND

Access to community-based specialist palliative care teams has been shown to improve patients' quality of life; however, the impact on health system expenditures is unclear. This study aimed to determine whether exposure to these teams reduces health system costs compared with usual care.

METHODS

We conducted a retrospective matched cohort study in Ontario, Canada, using linked administrative data. Decedents treated by 1 of 11 community-based specialist palliative care teams in 2009/10 and 2010/11 (the exposed group) were propensity score matched (comorbidity, extent of home care, etc.) 1 to 1 to similar decedents in usual care (the unexposed group). The teams are comprised of a core group of specialized physicians, nurses and other providers; their role is to manage symptoms around the clock, provide education and coordinate care. Our primary outcome was the overall difference in health system costs (among 5 health care sectors) between all matched pairs of exposed versus unexposed patients in the last 30 days of life.

RESULTS

The total cohort of decedents included 3109 matched pairs. Among matched pairs, the mean health system cost difference was $512 (95% confidence interval [CI] -$641 to -$383) lower in the last 30 days among exposed than among unexposed patients. In the last 30 days, the mean home care costs of the exposed group were $189 higher (95% CI -$151 to $227) than those of the unexposed group, but their mean hospital costs were $733 lower (95% CI -$950 to -$516).

INTERPRETATION

Our study suggests that health system costs are lower for patients who have access to community-based specialist teams than for those who receive usual care alone, largely because of decreased hospital costs. Ensuring access to in-home palliative care support, as provided by these teams, is an efficacious strategy for reducing health care expenditures at the end of life.

Peak Occurrence of Retinal Detachment following Cataract Surgery: A Systematic Review and Pooled Analysis with Internal Validation

Introduction

Timing of retinal detachment (RD) following cataract surgery is of importance for both diagnostic and prognostic factors. However, results on RD onset-time following cataract surgery have been conflicting.

Method

A systematic pooled analysis of the literature regarding timing of retinal detachment following cataract surgery. Outcomes were verified against an independent dataset.

Results

Twenty-one studies, reporting on rates of RD in 3,352,094 eyes of 2,458,561 patients, met our inclusion criteria and were included in the analysis. The mean pooled time to RD following surgery was 23.12 months (95% CI: 17.79-28.45 months) with high heterogeneity between studies (I ²=100%, P < 0.00001). Meta-analytic pooling for the risk of retinal detachment revealed a risk of 1.167% (95% CI: 0.900 to 1.468, I ²=99.50%, P < 0.0001). A retrospective chart review identified 54 pseudophakic RD cases (mean age 65.5, 59.3% males). The 95% confidence interval for the mean time to RD was 3.1-6.75 years.

Conclusions

The interval between cataract surgery and RD in a pooled analysis revealed a mean time of approximately 1.5-2.3 years. However, there was high variability between studies. Validation based on our local results showed similar yet slightly longer time frames. Timing of pseudophakic retinal detachment might direct appropriate follow-up, assisting in earlier detection.

Fin and body neuromuscular coordination changes during walking and swimming in Polypterus senegalus

The ability to modulate the function of muscle is integral to an animal's ability to function effectively in the face of widely disparate challenges. This modulation of function can manifest through short-term changes in neuromuscular control, but also through long-term changes in force profiles, fatiguability and architecture. However, the relative extent to which shorter-term modulation and longer-term plasticity govern locomotor flexibility remains unclear. Here, we obtain simultaneously recorded kinematic and muscle activity data of fin and body musculature of an amphibious fish, Polypterus senegalus After examining swimming and walking behaviour in aquatically raised individuals, we show that walking behaviour is characterized by greater absolute duration of muscle activity in most muscles when compared with swimming, but that the magnitude of recruitment during walking is only increased in the secondary bursts of fin muscle and in the primary burst of the mid-body point. This localized increase in intensity suggests that walking in P. senegalus is powered in a few key locations on the fish, contrasting with the more distributed, low intensity muscle force that characterizes the stroke cycle during swimming. Finally, the increased intensity in secondary, but not primary, bursts of the fin muscles when walking probably underscores the importance of antagonistic muscle activity to prevent fin collapse, add stabilization and increase body support. Understanding the principles that underlie the flexibility of muscle function can provide key insights into the sources of animal functional and behavioural diversity.

The Effect of CS Administration or an R-Optimized Alternative on Potential Projective Material in Rorschach Responses From Six Studies and a Meta-Analysis of Their Findings

The Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011) introduced R-optimized administration to reduce variability in the number of Responses (R). We provide new data from six studies of participants randomly assigned to receive a version of this method or Comprehensive System (CS; Exner, 2003) administration. We examine how administration methods affect 3 types of codes most likely to contain potential projective material and the frequency of these codes for the 1st, 2nd, 3rd, 4th, or last response to a card (R in Card). In a meta-analytic summary, we found 37% of responses have 1 type of code, 19% have 2 types, and 3% have all 3 types, with stable proportions across responses within cards. Importantly, administration method had no impact on potential projective variable means. Differential skew across samples made variability harder to interpret. Initial results suggesting differences in 3 of the 18 specific Type by R in Card pairs did not follow a coherent pattern and disappeared when using raw counts from all participants. Overall, data do not support concerns that R-optimized administration might alter potential projective processes, or make potentially "signature" last responses to the card any different in R-PAS than the CS.

Thyroid Function in Early Pregnancy, Child IQ, and Autistic Traits: A Meta-Analysis of Individual Participant Data

CONTEXT

Low maternal free T4 (FT4) has been associated with poor child neurodevelopment in some single-center studies. Evidence remains scarce for the potential adverse effects of high FT4 and whether associations differ in countries with different iodine status.

OBJECTIVE

To assess the association of maternal thyroid function in early pregnancy with child neurodevelopment in countries with a different iodine status.

DESIGN, SETTING, AND PARTICIPANTS

Meta-analysis of individual participant data from 9036 mother-child pairs from three prospective population-based birth cohorts: INMA [Infancia y Medio Ambiente (Environment and Childhood project) (Spain)], Generation R (Netherlands), and ALSPAC (Avon Longitudinal Study of Parents and Children, United Kingdom). The exclusion criteria were multiple pregnancies, fertility treatments, thyroid-interfering medication usage, and known thyroid disease.

MAIN OUTCOMES

Child nonverbal IQ at 5 to 8 years of age, verbal IQ at 1.5 to 8 years of age, and autistic traits within the clinical range at 5 to 8 years of age.

RESULTS

FT4 <2.5th percentile was associated with a 3.9-point (95% CI, -5.7 to -2.2) lower nonverbal IQ and a 2.1-point (95% CI, -4.0 to -0.1) lower verbal IQ. A suggestive association of hypothyroxinemia with a greater risk of autistic traits was observed. FT4 >97.5th percentile was associated with a 1.9-fold (95% CI, 1.0 to 3.4) greater risk of autistic traits. No independent associations were found with TSH.

CONCLUSIONS

Low maternal FT4 was consistently associated with a lower IQ across the cohorts. Further studies are needed to replicate the findings of autistic traits and investigate the potential modifying role of maternal iodine status. FT4 seems a reliable marker of fetal thyroid state in early pregnancy, regardless of the type of immunoassay.

Comparative effectiveness of 8- and 12-week ledipasvir/sofosbuvir regimens for HCV infection

BACKGROUND

Real-world studies have aimed to compare the effects of 8- and 12-week ledipasvir/sofosbuvir regimens on sustained virological response (SVR) among HCV infection genotype-1 (HCV-1) treatment-naive patients. Nevertheless, real-world comparative effectiveness studies pose unique challenges, such as confounding by indication, that were not adequately addressed in prior studies. We thus aimed to address limitations in prior studies and compare overall- and subgroup-specific effectiveness of 8- and 12-week ledipasvir/sofosbuvir regimens among HCV-1 treatment-naive patients.

METHODS

Patients eligible for our study were aged ≥18 years and initiated 8- or 12-week ledipasvir/sofosbuvir regimens for treatment-naive HCV-1 at an urban public hospital network. We excluded patients with HIV or cirrhosis. We used marginal structural models to estimate overall and subgroup-specific risk ratios (RRs) and 95% confidence limits (CL) comparing the effect of 8- and 12-week ledipasvir/sofosbuvir regimens on 12-week SVR.

RESULTS

Our study population comprised 191 patients. Among both regimens, the majority were aged >50 years, non-Hispanic White and uninsured. The overall risk of SVR was comparable between the 8- and 12-week regimens (RR=1.01, 95% CL: 0.92, 1.11). The risk of SVR did not vary by race/ethnicity (non-Hispanic Black: RR=1.01, 95% CL: 0.84, 1.21; non-Hispanic White: RR=1.01, 95% CL: 0.89, 1.04).

CONCLUSIONS

Our real-world results suggest that 8- and 12-week ledipasvir/sofosbuvir have comparable effects on SVR among HCV-1 patients without cirrhosis or HIV. In addition, the comparable effectiveness of 8- and 12-week regimens among non-Hispanic Black individuals adds to the growing body of evidence that supports the removal of race-based treatment guidelines.

Surgical Anatomy of the Superior Mesenteric Vessels Related to Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery.

METHODS

We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017.

RESULTS

Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases.

CONCLUSIONS

Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.

Diagnostic performance of cone beam computed tomography in assessing peri-implant bone loss: A systematic review

OBJECTIVES

To evaluate the diagnostic performance of cone beam computed tomography (CBCT) in the assessment of peri-implant bone loss and analyze its influencing factors.

MATERIALS AND METHODS

Clinical and preclinical studies reporting diagnostic outcomes of CBCT imaging of peri-implant bone loss compared to direct reference measurements were sought by searching five electronic databases, PubMed, MEDLINE, EMBASE, Web of Science, and CINAHL Plus, and OpenGrey. QUADAS-2 criteria were adapted for quality analysis of the included studies. A qualitative synthesis was performed. Two meta-analysis models (random-effects and mixed-effects) summarized the area under receiver operating characteristic (AUC) curve observations reported in the selected studies. The mixed-effects meta-analysis model evaluated three possible influencing factors, "defect type," "defect size," and "study effect."

RESULTS

The initial search yielded 3,716 titles, from which 18 studies (13 in vitro and 5 animal) were included. Diagnostic accuracy of CBCT was fair to excellent in detecting in vitro circumferential-intrabony and fenestration defects, but moderate to low for peri-implant dehiscences, and tended to be higher for larger defect sizes. Both, over- and underestimation of linear measurements were reported for the animal models. The meta-analyses included 37 AUC observations from eight studies. The random-effects model showed significant heterogeneity. The mixed-effects model exhibited also significant but lower heterogeneity, and "defect type" and "study effect" significantly influenced the variability of AUC observations.

CONCLUSION

In vitro, CBCT performs well in detecting peri-implant circumferential-intrabony or fenestration defects but less in depicting dehiscences. Influencing factors due to other site-related and technical parameters on the diagnostic outcome need to be addressed further in the future studies.